Newborn case presentation: history and immediate examination
THE CONTEXT
A newborn case presentation records maternal and perinatal history, feeding and postnatal problems, family circumstances, and findings immediately after birth.
Maternal and antenatal history
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Record the mother's name, age, parity, last menstrual period, and expected date of delivery.
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For previous pregnancies, document timing, gestation, fetal or neonatal problems, and the current status of the children.
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Record antenatal visits, hemoglobin testing, urine albumin and sugar, ultrasound, blood group, VDRL and HIV tests, tetanus toxoid immunization, and iron, folic acid, calcium and iodine supplementation.
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Document obstetric complications such as toxemia, urinary tract infections, multiple pregnancy, placenta previa and accidental hemorrhage; fetal problems such as IUGR, hydrops and Rh isoimmunization; and medical problems such as diabetes and hypertension.
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Include investigations, medications, and the course of any complications.
Labor, delivery and immediate care
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Record presentation, spontaneous or induced labor, spontaneous or artificial rupture of membranes, clear or meconium-stained liquor, duration of the first and second stages, and fetal heart rate abnormalities.
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Document the place and mode of delivery, cesarean indication and urgency where applicable, anesthesia, duration of the third stage, and postpartum hemorrhage.
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Record resuscitation, time of first breath and cry, Apgar score, cord care, and passage of urine and stool.
Feeding, postnatal and family history
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For breastfeeding, record initiation, frequency and adequacy, along with any other feeds.
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Ask about feeding problems, jaundice, eye discharge, fever, and current problems.
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Record perinatal illness in siblings, previous medical problems, socioeconomic status, and family support.
Examination immediately after birth
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Assess weight, gestation, congenital anomalies, sex assignment and Apgar scores, and examine the umbilical vessel and placenta.